Scottish Clinical Coding Standards

Transcription

1 Scottish Clinical Coding Standards Number 18 September 2018 Scottish Clinical Coding Standards ICD-10 ICD-10 V5 Errata The Terminology and Classifications Delivery Service of NHS Digital in England has identified and been informed of further errata in the printed ICD-10 V5 Edition volumes published by the World Health Organisation (WHO). These are listed in the tables below. Please amend your ICD-10 V5 books accordingly. Contents Scottish Clinical Coding Standards ICD ICD-10 V5 Errata...1 Scottish Clinical Coding Standards OPCS...2 Contraceptives...2 Human Fertilisation Codes...2 Skin Grafts...3 General Information...4 Available Courses...4 Certificate in Technical Competence in Clinical Coding...4 Staff News...5 Index Additions in 04/2018 Page Instruction Action Blue Underline insert text, Red Strikethrough delete text 392 Amend code Laceration (see also Wound, open) T14.1 -peritoneum, obstetric trauma O70.0 O Amend order of lead terms Pancolitis, ulcerative (chronic) K51.0 Pancoast s syndrome or tumor C34.1 Pancolitis, ulcerative (chronic) K Correct typographical error Assault (homicidal) (by) (in) Y09 -steam X98 Assault-continued -strangulation X91 Tabular Additions 04/18 Page Instruction Action Blue Underline insert text, Red Strikethrough delete text 464 Amend includes note J15.6 Pneumonia due to other Gram-negative bacteria Pneumonia (due to): Gram-negative (aerobic) bacteria NOS Serratia marcescens 504 Delete excludes note K29.6 Other gastritis Excl.: with gastro oesophageal reflux disease (K21.-) with Helicobacter pylori associated chronic gastritis (K29.5) 2018 NHS Digital, Re-used with the permission of NHS Digital. All rights reserved. For more information visit: 1

2 Scottish Clinical Coding Standards OPCS Contraceptives Insertion of a Nexplanon (Etonogestrel) implant is coded to S52.5 Insertion of hormone into subcutaneous tissue and replacement to S52.6 Replacement of hormone in subcutaneous tissue. Removal is coded to S62.5 Removal of hormone implant from subcutaneous tissue. Sayana Press (Medroxyprogesterone acetate) is an injectable contraceptive given subcutaneously and is coded to X38.3 Injection of hormone for local action NEC. Note that this code includes Injection of hormone NEC. Human Fertilisation Codes Recording of treatments provided under the Licence of the Human Fertilisation and Embryology Authority (HFEA). This article is designed to raise awareness for Medical Records and Information Managers who have a responsibility for managing the completion and submission of SMR data at Board level. The Human Fertilisation and Embryology Acts indicate that patients receiving Artificial insemination/in Vitro Fertilisation treatment from licensed centres should not be included on SMR returns to ISD as this would be in breach of the Acts. The codes and treatments concerned are as follows: ICD10 Z31.1 Artificial insemination Z31.2 In vitro fertilization Z31.3 Other assisted fertilization methods OPCS4 Q13 Introduction of gametes into uterine cavity Q21 Other introduction of gametes into uterine cavity Q38.3 Endoscopic intrafallopian transfer of gametes Y96 In vitro fertilisation It is important to stress that under the provisions of the Act, the Board should send information about such patients to the HFEA only and not to ISD*. If there are concerns then these should be raised with the Board s Caldicott Guardian. * The 2008 amendments to the Human Fertilisation and Embryology Act allow disclosure of information to certain other persons/bodies in particular circumstances, for example, including those where disclosure is to other persons or bodies discharging a regulatory function or for the purposes of medical research where the Secretary of State considers it necessary or expedient in the public interest or in the interests of improving patient care. These do therefore NOT apply to disclosure in the form of routine SMR reporting to ISD and this is still prohibited by the Act. (see 2

3 Skin Grafts When coding skin autografts the following details should be captured if the information is available: - type of autograft (split skin, full thickness, composite graft, pinch graft) - site of autograft - graft harvest -for a skin graft this should be coded as S04.8 Other specified other excision of skin (previous guidance used S Other specified other operations on skin). The skin autograft code implies the type of harvest. - site of harvest - if harvest site unknown, do not code the harvest - type of harvest - only Y58.1 Harvest of full thickness skin from postauricular region need be used when applicable, as it details both type and site of harvest The graft to + site must take priority over the harvest from + site in cases where coding space is limited. Example 1: Full thickness autograft to skin of back. Skin for graft harvested from thigh. S36.2 Full thickness autograft of skin NEC + Z49.4 Skin of back S04.8 Other specified other excision of skin + Z50.4 Skin of leg NEC Example 2: Excision of lump on nose with harvest of full thickness postauricular skin and full thickness skin graft to the nose. E09.1 Excision of lesion of external nose E09.7 Graft of skin to external nose + Y58.1 Harvest of full thickness skin from postauricular region. No separate site code is needed for E09.7 as the graft to site is stated in the code itself. The harvest can be coded simply by adding Y58.1 which records type of graft and site of the harvest. If the full thickness graft to the nose comes from another site the coding will be different. For example if the harvest site is the supraclavicular skin, the correct coding is E09.1 Excision of lesion of external nose E09.7 Graft of skin to external nose + S36.1 Full thickness Autograft of skin to head or neck S04.8 Other specified other excision of skin + Z49.6 Skin of shoulder This coding again captures graft to, type of graft, and harvest site. Example 3: Myringoplasty using temporalis fascia graft D Tympanoplasty using graft (includes Myringoplasty using graft) + Y60.8 Other specified other harvest of fascia It is not possible to add any further useful detail such as harvest site because a specific site code does not exist. This standard supercedes the previous guidance: Skin grafts Coding Guidelines 8 February 2001 PLEASE NOTE THAT ALL CODING STANDARDS IN THIS EDITION APPLY TO ALL DISCHARGES ON AND AFTER 1ST OCTOBER

4 General Information Available Courses Below is a list of courses currently available to all clinical coding staff, analysts and other Health Board staff. In the first instance please contact your line manager or supervisor to discuss your training needs. Your manager should then contact the Terminology Services Helpdesk for further information. Introduction to ICD-10/OPCS-4 ICD-10 Foundation Course OPCS-4 Foundation Course Bespoke refresher training, ICD-10 and OPCS-4 Mental Health Foundation course Overview of OPCS-4 Neoplasms workshop Orthopaedics workshop SMR02 maternity coding Introduction to Read Read in Child Health Introduction to SNOMED-CT Overview only of ICD-10/OPCS-4 e.g. analysts, other Health Board staff New coders New coders New coders in Mental Health For coders in non-acute hospitals Maternity coders New Coders in Primary Care Coders in Child Health Various Please our helpdesk if you have any suggestions for other workshops or specialist training. Certificate in Technical Competence in Clinical Coding Terminology Services are pleased to announce that six further candidates have now successfully completed the CTC in Clinical Coding. All candidates will receive their certificates in September. Terminology Services would like to congratulate them all (and their local mentors) for their hard work and achievement. Any clinical coder interested in working towards the CTC should, in the first instance, discuss this with their supervisor/manager. We recommend that new starts in Clinical Coding use the framework and supporting documentation to help in the early stages of their induction and training. By creating a Portfolio as they work through their local training programme and attending the Clinical Coding Foundation course, coders are then well on the way to providing the evidence required for formal assessment of their learning. Feedback from all current and previous candidates has been very positive. Information regarding the process, framework and syllabus can be found on our Terminology Services Advice and Support page here. 4

5 Staff News After more than 23 years as a coding tutor in ISD Julia (Ewen) has decided to hang up her coding books and retire at the end of September. Julia will be well missed. We wish her all the best for a great retirement. As a result of this and other staff changes, we thought it would be useful to revise tutor regional responsibilities. Please note the following changes to your lead regional tutor: Board name Main contact Second contact Lothian Abigail Hewitt and Graeme Elsby Borders, Fife, Forth Valley Abigail Hewitt Graeme Elsby Lanarkshire, Tayside Graeme Elsby Abigail Hewitt Greater Glasgow and Clyde Murray Bell and Lynsey Conroy Dumfries and Galloway, Golden Jubilee National Hospital Murray Bell Lynsey Conroy Ayrshire and Arran, Argyll and Bute Lynsey Conroy Murray Bell Grampian, Highlands, Western Isles, Tim Varley Shetland and Orkney Terminology training (Read and All tutors SNOMED CT). You can copy or reproduce the information in this document for use within NHS Scotland and for non-commercial educational purposes. Use of this document for commercial purposes is permitted only with the written permission of NSS. 5